October 26, 2020
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How Do Healthcare Facilities Maintain Compliance with JCAHO?

The Joint Commission on Accreditation of Healthcare Organizations is an independent, not-for-profit organization whose primary mission is to set standards and offer pathways to accreditation for healthcare organizations. The JCAHO, now known as The Joint Commission, advocates for the continuous improvement of the quality of care and standards of safety of healthcare practices by conducting surveys, identifying points for improvement and offering other platforms to support performance improvement of healthcare entities.

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Understanding the Accreditation Survey

Pursuing accreditation and certification is voluntary on the part of healthcare organizations. The survey is conducted by a team of accredited professionals who are experts in their field, including hospital administrators, doctors, nurses, medical technologists, and other healthcare professions. Regular survey schedules are unannounced, but surveys are conducted every 39 months except for laboratories where surveys are conducted once every 24 months. Results of the onsite survey are typically available within two weeks to two months after the survey date. However, accreditation is a continuous process because health organizations are asked to submit performance data on a consistent basis. Self-assessment surveys support the process of monitoring and improving standards of care. The accreditation is good for a period of three years for all health care organizations except for laboratories that have to re-certify every two years.

Focus on Accreditation Standards

The main goal of the Joint Commission is to define, monitor and support improvements in the delivery of healthcare with emphases on patient safety and quality standards of care. Currently, the accreditation standards include 250 points, covering infection control, medication safety, and management, error prevention and reporting, staff credentialing and certification, emergency management, patient rights, privacy, and education. Health organizations have to specify how patient and performance data is generated and how they use the information to improve standards and practices.

Pursuing and Maintaining Accreditation

The accreditation report is the comprehensive report produced by the Joint Commission survey team. It will include a list of RFIs or requirements for improvement as well as supplemental data and observations, all of which are part of the report sent to the Joint Commission Central Office and later posted to the extranet site for public access.

The number of RFIs submitted by the survey team can determine full accreditation or conditional accreditation. Health care organizations can either take corrective action or appeal the findings of the survey team. Within 45 days of the survey, the heallth organization must submit an ESC, which stands for evidence of standards compliance. This is a point-by-point report that outlines in detail any corrective action undertaken by the organization to address the cited RFI. The ESC must be accompanied by an MOS, also known as measure of success, which is a report generated by interviewing staff, conducting an audit and facility inspections to determine the effectiveness of the corrective action. The MOS is quantifiable with the performance tiers defined as follows: non-compliance for a 79 percent and below MOS, partial compliance for an MOS between 80 to 89 percent and satisfactory compliance for an MOS 90 percent and higher.

It is important for health care facilities to maintain compliance with JCAHO standards to assure stakeholders that they are operating effectively guided by the highest standards of care for the safety of patients and staff. Although a Joint Commission accreditation is voluntary, it is an indication of the organization’s commitment to delivering quality health care and pursuing best practices to ensure positive patient encounters and limit medical errors while supporting staff and public safety.